acl reconstruction - hamstring · acl reconstruction - hamstring dr elrashidy – tri-valley...

ACL RECONSTRUCTION - Hamstring

Dr Elrashidy – Tri-Valley Orthopedics

OVERVIEW

Focus on protection of graft and fixation in primary phases (Weeks 0 -12)

For ACL reconstruction with meniscal repair, defer to precautions in meniscal repair protocol.

The physician may alter time frames of brace-wear and use of crutches

Supervised Physical Therapy for 4-6 months

Use caution with hamstring stretching/strengthening based on donor site morbidity

GENERAL GUIDELINES

Ok to shower on post-op day 3. NO bathing/soaking knee until cleared by physician

Sleep with brace locked in extension x 1 week

Brace guidelines: Locked in full extension for 1st week (when walking and during sleep).

As quad function improves, begin unlocking brace gradually from Week 1 - Week 6

(15°-20° per week, fully unlocked at week 6). Discontinue brace after Week 6

Weight-bearing as tolerated by end of Week 1/start of Week 2

PHASE 1: Post-Op Through Week 6

Goals:

Protect graft and graft fixation with use of brace and specific exercises

Minimize effects of immobilization

Control inflammation and swelling (cryocuff/ice machine for first 2 weeks)

Full active and passive extension/hyperextension range of motion. Caution: avoid

hyperextension > 10°

Restore normal gait on level surfaces

No flexion past 90° until after Week 4 to protect graft fixation

Brace (Total Length = 6 weeks):

Week 1: Brace locked in full extension for ambulation and sleeping

Weeks 2-4: Unlock brace (goal of 90°) as quad function returns. Ok to d/c brace

when sleeping after first post-op visit (Day 10-14)

Week 5-6: Unlock brace completely from Week 5 to Week 6. Wean from brace

after Week 6, as patient demonstrates good quad control + normal gait mechanics

At Week 7-8: Brace on only in vulnerable situations (e.g. crowds, uneven terrain)

Weight-Bearing:

Week 1: Partial weight-bearing with crutches to assist with balance

Weeks 2 - 6: Progress to full weight-bearing with normal gait mechanics

Wean from crutches by 2 weeks and brace by 6 weeks as patient demonstrates

normal gait mechanics and good quad control (defined as lack of quadriceps lag)

ACL HAMSTRING PROTOCOL

Exercises:

Week 1: Maintain extension and work on passive and active-assisted flexion and

leg curls (progress to active leg curls as tolerated in Week 2)

Heel slides (limit to 90°)

Quad sets

Gastroc/Soleus stretching

Very gentle hamstring stretching at 1 week

Quad isometrics as 60° and 90°



SLR all planes: Brace on in full extension until quad strength sufficient to prevent

extension lag. Add weight as tolerated to hip abduction, adduction and extension.

If available, aquatic therapy (once sutures removed) to normalize gait, WB, and

strength. Deep-water aqua-jogging for ROM and swelling


PHASE 2: Weeks 7-12

Criteria for advancing to Phase 2:

Full Extension and Flexion to 90°

Good quad set, SLR without extension lag

Minimal swelling/inflammation

Normal gait on level surfaces

Goals:

Restore normal gait with stair climbing

Maintain full extension, progress towards full flexion

Increase hip, quadriceps, and calf strength

Increase proprioception

Exercises:

Continue with range of motion/flexibility exercises as appropriate for the patient

Initiate CKC quad strengthening and progress as tolerated (Wall sits, Step-ups,

Mini-squats, Leg press 90° – 30°, Lunges)



Progressive hip, hamstring, calf strengthening (gradually add resistance to open

chain hamstring exercises at week 12)

Continue Hamstring, Gastroc/Soleus stretches

Stairmaster (begin with short steps, avoid hyperextension)

Nordic Trac, Elliptical for conditioning

Stationary Bike (progressive time and resistance)

Single leg balance/proprioception (ball toss, balance beam, mini-tramp)


If available, pool-running (waist deep) or on unweighted treadmill @10-12 weeks

PHASE 3: Weeks 13 Through 18-20 Criteria for advancing to Phase 3:

No patellofemoral pain

Minimum of 120° of flexion

Sufficient strength + proprioception to initiate running (unweighted in pool)

Minimal swelling/inflammation

Goals:

Full range of motion

Improve strength, endurance + proprioception of extremity to prepare for sports

Avoid overstressing graft. Progressively increase resistance and hamstring

strengthening

Protect the patellofemoral joint

Normalize running mechanics

Strength 70% of uninvolved lower extremity per isokinetic evaluation

Exercises:

Continue flexibility and ROM exercises as appropriate for patient

Isokinetics (with anti-shear device). Begin with mid range speeds (120/sec-

240/sec)

Progress toward full weight-bearing running at about 16 weeks

Begin swimming if desired

Recommend isokinetic test with anti-shear device at 14-16 weeks to guide

continued strengthening

Progressive hip, quad, hamstring, calf strengthening

Cardiovascular/endurance training via stairmaster, elliptical, bike

Advance proprioceptive activities

PHASE 4: Month 5 Through Month 6

Criteria for advancing to Phase 4:

No significant swelling or inflammation

Full, pain-free ROM

No evidence of patellofemoral joint irritation

Strength 70% of uninvolved lower extremity per isokinetic evaluation

Sufficient strength and proprioception to initiate agility activities

Normal running gait



Goals:

Symmetric performance of basic and sport specific agility drills

Single hop and three hop tests 85% of uninvolved leg

Quadriceps and hamstring strength at least 85% of uninvolved lower extremity

per isokinetic strength test

Exercises:

Continue and progress flexibility and strengthening program based on individual

needs and deficits

Initiate plyometric program as appropriate for patient’s athletic goals

Agility progression including, but not limited to:

Side steps

Crossovers

Figure 8 running

Shuttle running

One leg and two leg jumping Cutting Acceleration/deceleration/springs Agility

ladder drills

Continue progression of running distance based on patient needs

Initiate sport-specific drills as appropriate for patient

Phase 5: Post-op Months 6-7 = RETURN TO SPORT

Hany Elrashidy, MD

Sports Medicine, Arthroscopy

Department of Orthopedic Surgery

Tri-Valley Orthopedic Specialists

acl reconstruction - hamstring · acl reconstruction - hamstring dr elrashidy – tri-valley...

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